1 The Impact on Behavior of Sexual Reproductive Health Programs for Young People Worldwide Douglas Kirby, Ph.D., ETR Associates September, 2010

International Technical Guidance on Sexuality Education: An evidence-informed approach for schools, teachers and health educators: Volume I UNESCO 2009 Available in Spanish 2

Volumen I: Justificación de la educación en sexualidad: Orientaciones Técnicas Internacionales sobre Educación en Sexualidad Un enfoque basado en evidencia orientado a escuelas, docentes y educadores de la salud 3

Throughout the world: Innumerable young women experience unintended pregnancy & childbearing Innumerable young women and men contract STIs, including HIV 4

Do solutions exist? There are no single magic solutions But there are partial solutions 5

Sexuality Education Programs 6

7 Study Criteria Programs had to:  Be a curriculum- and group-based sex or STI/HIV education program  Not only spontaneous discussion, only one-on-one interaction, or only broad school, community, or media awareness activities  Focus primarily on sexual behaviour, including abstaining and use of protection  As opposed to covering a variety of risk behaviours such as drug use, alcohol use, and violence in addition to sexual behaviour  Focus on adolescents up through age 24 outside of the U.S. or up through age 18 in the U.S.  Be implemented anywhere in the world.

8 Research methods had to: Include a reasonably strong experimental or quasi- experimental design with well-matched intervention and comparison groups and both pretest and posttest data. Have a sample size of at least 100. Measure programme impact on one or more of the following sexual behaviours for at least 3-6 months: −initiation of sex and frequency of sex, −number of sexual partners, −use of condoms and use of contraception more generally, −composite measures of sexual risk (e.g., frequency of unprotected sex. Study Criteria

9 Study had to:  Be completed by 1990  But did not have to be published in a peer-reviewed journal −Most were published in peer reviewed journals Study Criteria

Results 10

The Number of Comprehensive Programs with Indicated Effects Nearly all programs increased knowledge −Can be very important Important to ministers of education Important to the rights of young people to accurate information about sexality Some helped clarify values & attitudes, increased skills and improved intentions 11

12 The Number of Comprehensive Programs with Indicated Effects on Sexual Behaviors

13 The Number of Comprehensive Programs with Indicated Effects on Sexual Behaviors

14 The Number and Percent of Comprehensive Programs with Indicated Effects on:

15 Conclusions about the Impact of Sex and STD/HIV Education Programs  Sex/HIV education programs  Do not increase sexual activity  Some sex/HIV education programs:  Delay initiation of intercourse  Reduce number of sexual partners or  Increase use of condoms/contraception  Reduce unprotected sex  Pregnancy and STI rates (maybe – see next slide)  Some do two or more  Some do none of these

Impact on Pregnancy and STI Rates Most studies underpowered A few positive results on pregnancy and STI rates −Even with bio-markers Mema kwa Vijuana in Tanzania −Marginally powered −Had positive effects on behavior −No positive effects on either STI or pregnancy rates 16

Impact on Pregnancy and STI Rates U.S. CDC meta-analysis: −Pregnancy (N=11) RR =.89 Reduced pregnancy by 11% −STI (N=8) RR =.69 Reduced STI rate by 31% RR = Relative Risk 17

18 Conclusions about the Impact of Sex/HIV Education Programs continued  Programs are quite robust; they are effective with multiple groups:  Males and females  Sexually experienced and inexperienced  Youth in advantaged and disadvantaged communities  Different countries and regions in the world

19 Conclusions about the Impact of Sex/HIV Education Programs continued Sex and STI/HIV education programs:  Are not a complete solution  Can be an effective component in a more comprehensive initiative

20 Are programs effective when they are replicated by others?

21 California schools: 16 sessions  Delayed sex; increased contraceptive use Arkansas schools: 16 sessions  Delayed sex; increased condom use Kentucky schools: 16 sessions  Delayed sex; no impact on condom use* Kentucky schools: 12 sessions  Delayed sex; no impact on condom use Replications of Studies: Reducing the Risk

22 Philadelphia: 5 hours on Saturdays  Reduced sex & # partners; increased condom use Philadelphia: 8 hours on Saturdays  Reduced freq of sex; increased condom use 86 CBO in northeast: 8 hours on Saturdays  Increased condom use Philadelphia: 8 hours on Saturdays  Reduced sex & # partners; increased condom use Cleveland: 8 sessions in school  Deleted one condom activity  No significant effects on any behavior Replications of Studies: “Be Proud, Be Responsible” or “Making Proud Choices”

23 Jackson, Miss health center: minute sessions  Delayed sex; reduced frequency; increased condom use Residential drug treatment: minute sessions  Reduced sex & # partners; increased condom use Juvenile reformatory: 6 1-hour sessions  No effects Replications of Studies: Becoming a Responsible Teen

24 Replications of Studies: Focus on Kids Baltimore recreation center: 8 sessions  Increased condom use West Virginia rural areas: 8 90-minute sessions  Deleted some condom activities  No effects

25  Curricula can remain effective when implemented with fidelity by others!  Fidelity: All activities; similar structure  Substantially shortening programs may reduce behavioral impact  Deleting condom activities may reduce impact on condom use  Moving from voluntary after-school format to school classroom may reduce effectiveness Replications of Studies: Preliminary Conclusions

26 Your most promising strategy:  Implement programs with strong evidence that they were effective with populations similar to your own 1st Policy Implication

What are the characteristics of programs that changed behavior? 27

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29 Used a public health & logic model approach 1. Focused on the health goals (prevention of HIV, other STD, or pregnancy) 2. Specified the behaviors that cause or prevent HIV, other STD or pregnancy 3. Used theory, research, and personal experience to identify the psychosocial sexual risk and protective factors affecting those behaviors 4. Designed activities to affect those factors

30 Partial Example:

31 Focused on clear health goals - the prevention of STD/HIV and/or pregnancy  Talked about these health goals, including susceptibility and negative consequences  Gave a clear message about these goals  Identified behaviors leading to the health goal (see next characteristic)

32 Focused narrowly on specific behaviors leading to these health goals  Specified the behaviors  Gave clear messages about these behaviors  Addressed situations that might lead to them

33 What were the specific behaviors? STD/HIV  Delaying initiation of sex and not having sex  Number of partners (less commonly)  Condom use Pregnancy  Delaying initiation of sex and not having sex  Contraceptive use

34 What was the clear message about behavior?  Emphasized not having sex as safest and best approach  Encouraged condom/contraceptive use for those having sex  The clear messages were appropriate for age, sexual experience, gender and culture  Sometimes also emphasized other values: Be proud, be responsible, respect yourself, stick to your limits, remain in control (for women)

35 Discussed specific situations that might lead to unwanted or unprotected sex and how to avoid them or get out of them

36 Addressed multiple sexual psychosocial risk and protective factors affecting sexual behaviors −Used theory to identify factors Social learning theory Theory of planned behavior Theory of reasoned action Health belief model

37 Improved targeted psychosocial factors :  Overall knowledge of sexual issues  Knowledge of pregnancy, STD and HIV, condom/ contraceptive use  Personal values about sex and abstaining from sex  Attitudes toward condoms, perceptions of effectiveness and barriers to use  Perception of peer norms about sex & condoms  Self-efficacy to refuse sex or to use condoms  Intention to abstain from sex, restrict sex or partners or use condoms  Communication with parents or other adults about sex, condoms or contraception

38 Included multiple activities to change each of the targeted risk and protective factors

39  Data on the incidence or prevalence of pregnancy or STD/HIV (sometimes among youth) and their consequences  Class discussions  HIV+ speakers  Videos, handouts, etc.  Simulations STD handshake Monthly pregnancy risk Immediate and long term effects on own lives Included activities to address risk (susceptibility and severity)

40  Clear message  Discussions of effectiveness  Peer surveys/voting  Discussions of barriers where to get how to minimize hassle & loss of enjoyment  Visits to drug stores or clinics  Peer modeling of insisting on using condoms Discussion of lines, role plays Included activities to change individual attitudes & peer norms about condoms or contraception

41 1.To avoid unwanted sex and unprotected sex 2.To insist on and use condom or contraception 3.To use condoms correctly Included activities to improve three skills:

42  Description of skills  Modeling of skills  Individual practice in skills -- Role playing Everyone practices Repetition Increasing difficulty Increasing use of own words  Feedback (e.g., checklist) To avoid unwanted/unprotected sex and to insist on using condoms or contraception

43 1.Arrange in order the proper steps for using condoms 2.Model and practice opening package and putting condoms over fingers, verbally stating and following the important steps To use condoms properly

44 Included instructionally effective activities to increase communication with parents or adults about sex (occasionally)  Homework assignments Information sent home to parents Multiple assignments

Summary: Employed effective teaching methods  Were instructionally sound E.g., role playing to improve skills  Actively involved participants  Helped them personalize the information  Were appropriate to the youths’ culture, developmental age, gender and sexual experience 45

Structure of School-Based Programs Lasted at least 10 sessions −Sometimes 20 or more sessions Programs with effects > 2 years −Sequential E.g., Safer Choices −10 sessions 9 th grade −10 sessions 10 th grade −School-wide components all years 46

Other Recommendations Ensure supportive policies are in place Select capable and motivated educators Provide training, support and monitoring 47

48 Thank You